The son of a woman killed in a Romford fire is renewing his bid for a jury inquest into her death, claiming an official report has revealed systemic failures in her care.
The High Court this month rejected Gary Parkin’s legal action against the East London Coroners’ Service, over its refusal to let a jury deliberate over his mother Rosslyn Wolff’s death.
But he has filed an appeal citing new evidence – a report by the North East London NHS Foundation Trust (NELFT), the mental health service which was treating Rosslyn before her death.
He claims the report demonstrates a years-long “systemic” failure which contributed to Rosslyn’s death.
Rosslyn, 74, died in a fire at her home in Myrtle Road, Harold Hill, in January 2022.
NELFT has previously admitted “individual failings” in her care, but lobbied against an Article 2 (jury) inquest, claiming they did not amount to a systemic issue.
On May 12, retired High Court judge Sir Duncan Ouseley rejected Gary’s request for a judicial review over the inquest decision, saying he had not shown an “arguable error of law”.
But Gary has since requested an oral hearing.
Days earlier, he said, he finally received a copy of NELFT’s official report into the care it provided to his mother, signed off in September 2022.
'Faeces and fleas'
Rosslyn first came to the attention of NELFT in 2015, the report said.
“Between 2015 and 2021, Rosslyn’s son raised concerns regarding his mother’s property,” it noted.
“He described the property as uninhabitable with dog faeces, fleas and excessive clutter. These concerns were also shared with the director of adult social services (local authority).”
In 2019, Havering Council’s Older Adult Mental Health Team and Adult Social Care visited Rosslyn’s home, finding it “extremely dirty”.
She was wearing “dirty clothes” and said she “had not attended to her personal care in three weeks”.
She initially agreed to accept a care package and allow a “deep clean” of her home, but then stopped engaging.
Her lack of engagement was accepted, Gary contends, because she was deemed to have decision-making capacity.
He and his aunt (Rosslyn’s sister) continually raised concerns about Rosslyn’s capacity with NELFT, Gary said, believing she was suffering from dementia.
NELFT’s report has now concluded that she suffered from delirium, a “transient” problem which explained why she sometimes seemed to have capacity and at other times did not.
Confusion
In July 2021, health workers made an unannounced visit to Rosslyn’s home.
She would not let them in and they noted “no evidence of cognitive or mental capacity concerns”.
They discharged her as a NELFT patient.
But seven weeks later she was referred back to NELFT by Essex Police, who had found her in Colchester in a confused state.
A medical practitioner also found her to be “confused and not making sense” on the same day.
She was sectioned, but released hours later.
Two weeks later, she was sectioned again after being found by police wandering the streets of Cambridgeshire, "appearing confused and paranoid”.
The NELFT report said it was “clearly identified and documented that there were possible issues regarding Rosslyn’s capacity.”
Despite this, Rosslyn “did not have a formal capacity assessment” and “therefore it is unclear whether Rosslyn had a full understanding of the risk posed by her living conditions”, the report said.
Fire hazard
In October 2021, a consultant had even said Rosslyn should specifically be tested for her capacity to “understand the risks she was exposed to through her home environment”.
That never happened.
A fire risk assessment was also deemed necessary, given the combination of Rosslyn’s mental health and living conditions.
That never happened either.
When mental health workers visited Rosslyn in October 2021, they “noted concern regarding the state of the property” and wrote that they would visit her again.
But they did not visit again.
Instead, she was discharged as a patient again eight days later.
Reaction
“We’ve got clear evidence that everybody knew the risk she posed to herself and others, but she was never tested for capacity,” said Gary.
“They never looked behind the issues. They just brushed everything under the carpet.
“This is not individual negligence. This is collective negligence.”
The author of NELFT’s report, investigator Jay Brown, wrote: “In my opinion Rosslyn suffered delirium and did not have dementia.
“Unfortunately, because of her lack of engagement, we could have not possibly and practically undertaken a detailed cognitive test.”
NELFT and the coroners’ service said they were legally unable to comment further.
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